Food Stamps Application
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LDSS-4826-RU (Rev. 5/05)
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NYS Agency-Based Voter Registration Form ESTE FORMULARIO ESTA DISPONIBLE EN ESPANOL
IMPORTANT!
"If you are not registered to vote where you live now, would you like to apply to register here today?"
YES
Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.
( If you check yes, please complete VOTER REGISTRATION APPLICATION at bottom of page)
NO because I choose not to register OR I am already registered at my current address OR I asked for and received a mail registration form.
If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private.
If you do not check any box, you will be considered to have decided not to register to vote at this time. _______________________________________ (Signature)
If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with:
_____/_____/________ (Date)
____________________________________________________________ (Please Print Name)
Qualifications for Registration
New York State Board of Elections, 40 Steuben Street, Albany, New York 12207-2109 Telephone: 1-800-469-6872; TDD/TTY users contact the New York State Relay at 711; or visit our web site - www.elections.state.ny.us
You Can Use This Form To:
• • •
register to vote in New York State; change your name and/or address, if there is a change since you last voted; enroll in a political party or change your enrollment.
To Register You Must:
• • • • •
Your decision to register will remain confidential and will be used only for voter registration purposes. Anyone not choosing to register to vote and/or information regarding the office to which the application was submitted will remain confidential, to be used only for voter registration purposes.
be a U.S. citizen; be 18 years old by December 31 of the year in which you file this form (note: You must be 18 years old by the date of the general, primary, or other election in which you want to vote.); be a resident of the County, or of the City of New York at least 30 days before an election; not be in jail or on parole for a felony conviction; not claim the right to vote elsewhere.
-----------------------------------------------------------------------------------------------------------------------------------VOTER REGISTRATION APPLICATION (instructions on back) NVRA-05 (01/07) Yes, I need an application for an Absentee Ballot
1
3 4 5 6
Are you a U.S. citizen? Yes No If you answered NO, do not complete this form. Last Name
Middle Initial
Apt. No.
Address where you get your mail (if different from above)
The last year you voted
7
Sex (circle) M
F
8
City/Town/Village
Zip Code
P.O. box, star route., etc.
Post Office
Home Tel. Number (optional)
Your Address was (give house number, street, and city)
Under the Name (if different from your name now)
DEMOCRATIC PARTY REPUBLICAN PARTY INDEPENDENCE PARTY 11 CONSERVATIVE PARTY WORKING FAMILIES PARTY *See reverse OTHER (write in) _____________________________ I DO NOT WISH TO ENROLL IN A PARTY
County
Zip Code
ID Number - Check the applicable box and provide your number New York DMV number __ __ __ __ __ __ __ __ __ If you do not have a New York DMV number, please provide: Last four digits of your Social Security Number __ __ __ __ I do not have a New York Driver’s license number or a Social Security Number
AFFIDAVIT: I swear or affirm that
Choose a Party - Check one box only Please note: In order to vote in a primary election, you must be enrolled in one of these parties.
For Board use only!
Suffix
9 10 In county/state
Yes, I would like to be an Election Day worker
Will you be 18 years old on or before election day? Yes No If you answered NO, do not complete this form unless you will be 18 by the end of the year.
First Name
Address where you live (do not give P.O. address)
Date of Birth
2
Please print or type in blue or black ink
12
• • • • •
I am a citizen of the United States I will have lived in the county, city, or village for at least 30 days before the election. I meet all requirements to register to vote in New York State. This is my signature or mark on the line below. The above information is true. I understand that if it is not true I can be convicted and fined up to $5,000 and/or jailed for up to four years.
____________________________________________ (Signature or Mark in Ink)
(Date)
IDENTIFICATION REQUIREMENTS Your identity must be verified prior to election day, so that you will not have to provide identification when you vote. Your identity can be verified through your DMV number (driver's license number or non-driver ID number), or the last four digits of your social security number, as requested in Box 9 of this application. If your identity is not verified before election day, you will be asked to provide identification when you vote for the first time. Samples of the identification you may provide include a valid photo ID, a current utility bill, bank statement, government check or some other government document that shows your name and address.
TO COMPLETE THIS FORM: Box 9: Must be completed. If you have a current New York Box 1: Must be completed. If you answer NO, do not driver's license, you must provide that number. If you do not complete this form.
have a current New York driver's license, you must provide the last four digits of your social security number.
Box 2: Must be completed, however if you check NO, do not
complete this form UNLESS you are a New York resident Box 10: If you have never voted before, write "None." If you can't remember when you last voted, put a question mark who will be 18 by the end of this year. (?). If you voted before under a different name, put down that name. If not, write "Same." Box 4: Give your home address.
Box 5: Give your mailing address if it is different from your
Box 11: In order to vote in a party primary, you must be
enrolled in one of New York's 5 constituted parties. Check home address (post office box no., star route or rural route one box only. (*Except the Independence Party, which no., etc.) permits non-enrolled voters to vote in their primary elections.) Box 8: The completion of this box is optional.
Box 12: This application must be signed and dated in ink.
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ACCESS NYC ACCESS NYC ID: N/A
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ACCESS NYC ACCESS NYC ID: N/A
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LDSS-4826-RU (Rev. 5/05)
ACCESS NYC ACCESS NYC ID: N/A
I6
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LDSS-4826-RU (Rev. 5/05)
ACCESS NYC ACCESS NYC ID: N/A
I7
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LDSS-4826-RU (Rev. 5/05)
ACCESS NYC ACCESS NYC ID: N/A
I8
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LDSS-4826-RU (Rev. 5/05)
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NYS Agency-Based Voter Registration Form ESTE FORMULARIO ESTA DISPONIBLE EN ESPANOL
IMPORTANT!
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YES
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( If you check yes, please complete VOTER REGISTRATION APPLICATION at bottom of page)
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If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private.
If you do not check any box, you will be considered to have decided not to register to vote at this time. _______________________________________ (Signature)
If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with:
_____/_____/________ (Date)
____________________________________________________________ (Please Print Name)
Qualifications for Registration
New York State Board of Elections, 40 Steuben Street, Albany, New York 12207-2109 Telephone: 1-800-469-6872; TDD/TTY users contact the New York State Relay at 711; or visit our web site - www.elections.state.ny.us
You Can Use This Form To:
• • •
register to vote in New York State; change your name and/or address, if there is a change since you last voted; enroll in a political party or change your enrollment.
To Register You Must:
• • • • •
Your decision to register will remain confidential and will be used only for voter registration purposes. Anyone not choosing to register to vote and/or information regarding the office to which the application was submitted will remain confidential, to be used only for voter registration purposes.
be a U.S. citizen; be 18 years old by December 31 of the year in which you file this form (note: You must be 18 years old by the date of the general, primary, or other election in which you want to vote.); be a resident of the County, or of the City of New York at least 30 days before an election; not be in jail or on parole for a felony conviction; not claim the right to vote elsewhere.
-----------------------------------------------------------------------------------------------------------------------------------VOTER REGISTRATION APPLICATION (instructions on back) NVRA-05 (01/07) Yes, I need an application for an Absentee Ballot
1
3 4 5 6
Are you a U.S. citizen? Yes No If you answered NO, do not complete this form. Last Name
Middle Initial
Apt. No.
Address where you get your mail (if different from above)
The last year you voted
7
Sex (circle) M
F
8
City/Town/Village
Zip Code
P.O. box, star route., etc.
Post Office
Home Tel. Number (optional)
Your Address was (give house number, street, and city)
Under the Name (if different from your name now)
DEMOCRATIC PARTY REPUBLICAN PARTY INDEPENDENCE PARTY 11 CONSERVATIVE PARTY WORKING FAMILIES PARTY *See reverse OTHER (write in) _____________________________ I DO NOT WISH TO ENROLL IN A PARTY
County
Zip Code
ID Number - Check the applicable box and provide your number New York DMV number __ __ __ __ __ __ __ __ __ If you do not have a New York DMV number, please provide: Last four digits of your Social Security Number __ __ __ __ I do not have a New York Driver’s license number or a Social Security Number
AFFIDAVIT: I swear or affirm that
Choose a Party - Check one box only Please note: In order to vote in a primary election, you must be enrolled in one of these parties.
For Board use only!
Suffix
9 10 In county/state
Yes, I would like to be an Election Day worker
Will you be 18 years old on or before election day? Yes No If you answered NO, do not complete this form unless you will be 18 by the end of the year.
First Name
Address where you live (do not give P.O. address)
Date of Birth
2
Please print or type in blue or black ink
12
• • • • •
I am a citizen of the United States I will have lived in the county, city, or village for at least 30 days before the election. I meet all requirements to register to vote in New York State. This is my signature or mark on the line below. The above information is true. I understand that if it is not true I can be convicted and fined up to $5,000 and/or jailed for up to four years.
____________________________________________ (Signature or Mark in Ink)
(Date)
IDENTIFICATION REQUIREMENTS Your identity must be verified prior to election day, so that you will not have to provide identification when you vote. Your identity can be verified through your DMV number (driver's license number or non-driver ID number), or the last four digits of your social security number, as requested in Box 9 of this application. If your identity is not verified before election day, you will be asked to provide identification when you vote for the first time. Samples of the identification you may provide include a valid photo ID, a current utility bill, bank statement, government check or some other government document that shows your name and address.
TO COMPLETE THIS FORM: Box 9: Must be completed. If you have a current New York Box 1: Must be completed. If you answer NO, do not driver's license, you must provide that number. If you do not complete this form.
have a current New York driver's license, you must provide the last four digits of your social security number.
Box 2: Must be completed, however if you check NO, do not
complete this form UNLESS you are a New York resident Box 10: If you have never voted before, write "None." If you can't remember when you last voted, put a question mark who will be 18 by the end of this year. (?). If you voted before under a different name, put down that name. If not, write "Same." Box 4: Give your home address.
Box 5: Give your mailing address if it is different from your
Box 11: In order to vote in a party primary, you must be
enrolled in one of New York's 5 constituted parties. Check home address (post office box no., star route or rural route one box only. (*Except the Independence Party, which no., etc.) permits non-enrolled voters to vote in their primary elections.) Box 8: The completion of this box is optional.
Box 12: This application must be signed and dated in ink.
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